Functional Medicine Intake — Just For The Health Of It

Functional Medicine Patient Intake Form Part 1 of 3

Order Number

First Name *

Last Name *

Birthdate *

Email Address *

Where did you hear about us? *

Select the appropriate choice for each question.

0 almost never happens

1 rarely happens

2 sometimes happens

3 almost always happens

Section 1

Low brain endurance for focus and concentration *

Cold hands and feet *

Must exercise or drink coffee to improve brain function *

Poor nail health *

Fungal growth on toenails *

Must wear socks at night *

Nail beds are white instead of pink *

The tip of the nose is cold *

Section 2

Irritable, nervous, shaky, or light-headed between meals *

Feel energized after meals *

Difficulty eating large meals in the morning *

Energy level drops in the afternoon *

Crave sugar and sweets in the afternoon *

Wake up in the middle of the night *

Difficulty concentrating before eating *

Depend on coffee to keep going *

Section 3

Fatigue after meals *

Sugar and sweet cravings after meals *

Need for a stimulant, such as coffee, after meals *

Difficulty losing weight *

Increased frequency of urination *

Difficulty falling asleep *

Increased Appetite *

Section 4

Always have projects and things that need to be done *

Never have time for yourself *

Not getting enough sleep or rest *

Difficulty getting regular exercise *

Feel that you are not accomplishing your life's purpose *

Section 5

Dry and unhealthy skin *

Dandruff or a flaky scalp *

Consumption of processed foods that are bagged or boxed *

Consumption of fried foods *

Difficulty consuming raw nuts or seeds *

Difficulty consuming fish (not fried) *

Difficulty consuming olive oil, avocados, flax seed oil, or natural fats *

Section 6

Difficulty digesting foods *

Constipation or inconsistent bowel movements *

Increased bloating or gas *

Abdominal distention after meals *

Difficulty digesting protein-rich foods *

Difficulty digesting starch-rich foods *

Difficulty digesting fatty or greasy foods *

Difficulty swalloing supplements or large bites of food *

Abnormal gag reflex *

Yes

Section 7

Brain fog (unclear thoughts or concentration) *

Yes

Pain and inflammation *

Yes

Noticeable variations in mental speed *

Yes

Brain fatigue after meals *

Brain fatigue after exposure to chemicals, scents, or pollutants *

Brain fatigue when the body is inflamed *

Section 8

Grain consumption leads to tiredness *

Grain consumption makes it difficult to focus and concentrate *

Feel better when bread and grains are avoided *

Grain consumption causes the development of any symptoms *

A 100% gluten-free diet *

Yes

Section 9

A diagnosis of celiac disease, gluten sensitivity, hypothyroidism, or an autoimmune disease *

Yes

Family members who have been diagnosed with an autoimmune disease *

Yes

Family members who have been diagnosed with celiac disease or gluten sensitivity *

Yes

Changes in brain function with stress, poor sleep, or immune activation *

Section 10

A loss of pleasure in hobbies and interests *

Feel overwhelmed with ideas to manage *

Feelings of inner rage or unprovoked anger *

Feelings of paranoia *

Feelings of sadness for no reason *

A loss of enjoyment in life *

A lack of artistic appreciation *

Yes

Feelings of sadness in overcast weather *

A loss of enthusiasm for favorite activities *

A loss of enjoyment in favorite foods *

A loss of enjoyment in friendships and relationships *

Inability to fall into deep, restful sleep *

Feelings of dependency on others *

Feelings of susceptibility to pain *

Section 11

Feelings of worthlessness *

Feelings of hopelessness *

Self-destructive thoughts *

Inability to handle stress *

Anger and aggression while under stress *

Feelings of tiredness, even after many hours of sleep *

A desire to isolate yourself from others *

An unexplained lack of concern for family and friends *

An inability to finish tasks *

Feelings of anger from minor reasons *

Section 12

A decrease in visual memory (shapes and images) *

Yes

A decrease in verbal memory *

Occurrence of memory lapses *

A decrease in creativity *

A decrease in comprehension *

Difficulty calculating numbers *

Difficulty recognizing objects and faces *

A change in opinion about yourself *

Slow mental recall *

Section 13

A decrease in mental alertness *

A decrease in mental speed *

A decrease in concentration quality *

Slow cognitive processing *

Impaired mental performance *

An increase in the ability to be distracted *

Need coffee or caffeine sources to improve mental function *

Section 14

Feelings of nervousness or panic for no reason *

Feelings of dread *

Feelings of a knot in your stomach *

Feelings of being overwhelmed for no reason *

Feelings of guilt about everyday decisions *

A restless mind *

An inability to turn off the mind when relaxing *

Disorganized attention *

Worry over things never thought about before *

Feelings of inner tension and inner excitability *